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Gated SPECT Myocardial Perfusion Imaging with Cadmium-Zinc-Telluride Detectors Allows Real-Time Assessment of Dobutamine-Stress

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Gated SPECT Myocardial Perfusion Imaging with Cadmium-Zinc-Telluride Detectors Allows Real-Time Assessment of Dobutamine-Stress ORIGINAL ARTICLE Gated SPECT myocardial perfusion imaging with cadmium-zinc-telluride detectors allows real- time assessment of dobutamine-stress-induced wall motion abnormalities Rene Nkoulou, MD,a,b Mathias Wolfrum, MD,a Aju P. Pazhenkottil, MD,a Michael Fiechter, MD,a Ronny R. Buechel, MD,a Oliver Gaemperli, MD,a and Philipp A. Kaufmann, MDa a Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland b Department of Cardiology, University Hospital Geneva, Geneva, Switzerland Received Mar 25, 2017; accepted Dec 18, 2017 doi:10.1007/s12350-018-1187-x Background. Left ventricular (LV) ejection fraction (EF) during high dobutamine stress (HD) by real-time gated-SPECT myocardial perfusion imaging (MPI) on a cadmium-zinc- telluride (CZT) gamma camera was validated versus cardiac magnetic resonance imaging (CMR). Methods and results. After injecting 99mTc-tetrofosmin (320 MBq) in 50 patients (mean age 64 1/2 11 years), EF at rest and post-stress as well as relevant changes in EF at HD (DEF ‡ 5%) were assessed. CZT and CMR rest EF values yielded an excellent correlation and agreement (r = 0.96; P < 0.001; Bland–Altman limits of agreement (BA): 1 0 to 14.8%). HD EF acquisition was feasible using CZT and correlated better to HD CMR EF than did post-stress CZT EF (r = 0.85 vs 0.76, respectively, all P < 0.001). Agreement in DEF detection between HD CMR and immediate post-stress CZT (reflecting standard acquisition using conventional SPECT camera unable to scan during stress) was 45%, while this increased to 85% with real- time HD CZT scan. Conclusion. Real-time ultrafast dobutamine gated-SPECT MPI with a CZT device is feasible and provides accurate measurements of HD LV performance. (J Nucl Cardiol 2019;26:1734–42.) Key Words: Cadmium-zinc-telluride detectors gamma camera Æ Dobutamine-stress Æ Wall motion abnormalities Abbreviations LVWT Left ventricular wall thickening CMR Cardiac magnetic resonance imaging MPI Myocardial perfusion imaging CZT Cadmium-zinc-telluride detectors TID Transient ischemic dilation SPECT single photon emission computed tomography LVWM Left ventricular wall motion See related editorial, pp. 1743–1745 Electronic supplementary material The online version of this Reprint requests: Rene Nkoulou, MD, Department of Nuclear Medi- article (https://doi.org/10.1007/s12350-018-1187-x) contains sup- cine, University Hospital Zurich, Rðmistrasse 100, 8091 Zurich, plementary material, which is available to authorized users. Switzerland; [email protected] The authors of this article have provided a PowerPoint file, available 1071-3581/$34.00 for download at SpringerLink, which summarises the contents of the Copyright Ó 2018 American Society of Nuclear Cardiology. paper and is free for re-use at meetings and presentations. Search for the article DOI on SpringerLink.com. 1734 Journal of Nuclear CardiologyÒ Nkoulou et al. 1735 Volume 26, Number 5;1734–42 Myocardial perfusion imaging, CZT detector gamma camera, dobutamine INTRODUCTION study was approved by the local ethics committee and all study participants provided written informed consent. Myocardial perfusion imaging (MPI) using single photon emission computerized tomography (SPECT) is one of the best established imaging modalities for the Stress Protocol non-invasive detection of patients with coronary artery After a rest ECG and obtaining an intravenous line, disease (CAD). This is partly due to the fact that dobutamine was administered intravenously by an infu- perfusion abnormalities, which are the target of SPECT sion pump, starting at a low dose of 10 ug/kg/min (LD) MPI, occur very early in the ischemic cascade.1 Imple- for 5 minutes and then increasing by 10 ug/kg/min every mentation of ECG-gated acquisition has improved the 3 minutes, to achieve 85% of age-predicted maximal accuracy of SPECT as it allows to distinguish between heart rate (220-age), up to a maximum of 40 ug/kg/min. true fixed defects and attenuation artifacts2 and it Atropine 0.5 to 1 mg iv was added whenever needed to confers an added prognostic value over MPI alone.3 achieve the target heart rate. Throughout the pharmaco- Dynamic changes in global and regional LV contractil- logic stress continuous 12-lead ECG and intermittent ity under stress conditions are a strong predictor of blood pressure monitoring were recorded. Dobutamine adverse events in a wide range of cardiovascular was stopped prior to reaching the target heart rate in case conditions including CAD,4-6 dilated cardiomyopathy,6 of severe hypertensive response (blood pressure [ 220/ and valvular dysfunction.7 120 mm hg), systolic hypotension (\80 mm Hg), blood The current SPECT gamma camera generation pressure drop [ 40 mm Hg compared to baseline, requires an acquisition time for MPI and gated-SPECT significant arrhythmia, horizontal or downsloping ST of 15 minutes or longer. This precludes an assessment of segment depression [ 0.20 mV at an interval of 80 ms LV function and diameter during maximal stress. Thus, from the J point compared to baseline, ST segments the widely used transient ischemic dilation (TID) is elevation [ 0.1 mV in patients without previous based on values assessed after stress, and could therefore myocardial infarction.10 be subject to changes due to early recovery during the relatively long scan period. The latest generation of SPECT cameras with cadmium-zinc-telluride (CZT) SPECT Data Acquisition and Reconstruction detector technology offers ultrafast MPI assessment at All SPECT MPI’s were performed on a hybrid 3 minutes acquisition time8,9 and may therefore be CZT/CT device (DNM 570c, GE Healthcare, Milwau- potentially used for sequential real-time EF acquisition kee). The CZT part is a gamma-camera equipped with by gated-SPECT at each step of a standard dobutamine 19 non-rotating CZT solid state detector modules stress protocol. We thus aimed at evaluating the feasi- positioned around the chest.11-13 This camera enables bility of EF measurements and its accuracy to detect low-dose radiotracer MPI acquisition within 3 minutes clinically relevant changes in EF (DEF) during standard and high-dose radiotracer acquisition within 2 minutes.8 dobutamine stress protocol assessed by real-time high- After a CT scan for attenuation correction,14,15 320 MBq speed gated-SPECT using cardiac magnetic resonance of 99mTc-tetrofosmin were injected, and MPI as well as imaging (CMR) with dobutamine stress as standard of LV function were assessed at rest twice consecutively reference. over 3 minutes each. Thereafter, dobutamine was started and LV function was assessed from gated-MPI (3 MATERIAL AND METHODS minutes acquisitions each) after reaching a steady-state during low-dose dobutamine (LD) (10 ug/kg/min) and at Patient Population peak-stress during maximum dobutamine dose (HD). Immediately after finishing HD image acquisition, 960 Fifty consecutive patients referred for SPECT MPI MBq of 99mTc-tetrofosmin was injected while dobu- were enrolled for the feasibility study (including repro- tamine was continued for 1 more minute and gated post- ducibility and repeatability for the rest scan). Exclusion stress images were acquired 5 min later. Thus, this criteria were any contraindication to dobutamine includ- protocol allows assessing MPI at rest and at HD stress, ing recent unstable angina, uncontrolled hypertension, but also allows LV functional data at rest, at LD and aortic aneurysmal disease, or severe aortic stenosis. An HD, as well as early post-stress. The latter reflects the additional rest/dobutamine-CMR was performed in a traditional setting with a standard SPECT camera which subgroup of 20 within 2 weeks during which no change does not allow real-time LV function assessment in clinical condition including medication or revascu- because acquisition time exceeds by far the short time larization occurred for validation of the precision. The of HD dobutamine tolerable by patients. The widely used TID is based on such post-stress data which may 1736 Nkoulou et al. Journal of Nuclear CardiologyÒ Myocardial perfusion imaging, CZT detector gamma camera, dobutamine September/October 2019 substantially differ from the real value at stress. All Systems, Best, the Netherlands) with prospective ECG- SPECT images were acquired with ECG gating and in triggering. Scout images served to determine 4-chamber, list-mode.9,11 A schematic representation of the scan- 2-chamber, 3-chamber views, and 3 basal to apical ning protocol is displayed in Figure 1. short-axis views of the left ventricle. Volume measure- Reconstruction of gated-SPECT was performed ments were obtained after multiphase gradient-echo using dedicated software (Myovation for Alcyone, GE (repetition time/echo time 30/10 ms, section thickness Healthcare, Milwaukee) including CT-based attenuation 10 mm, flip angle 40-50, matrix of 128 9 128 correction as previously described14 and validated for reconstructed in 256 9 256). Measurements during LD this CZT device15: list-mode files were used to generate and HD were performed after injection of contrast media 2 separate rest MPI gated scans (3 minutes each). All used for rest perfusion evaluation (0.1 mmol of gadolin- scans were rebinned into 8 frames encompassing the ium per kilogram of body weight, Gadovist 1.0; Bayer entire R-R interval with a 10% acceptance window for Schering Pharma, Berlin, Germany). LV volumes were bad-beat rejection. Reconstructed files were analyzed calculated from the gradient-echo MR images using an using the commercially available QGS/QPS software analytical software package (QMass MR, version 7.2; package (Cedars Sinai, California, USA) yielding quan- Medis Medical Imaging systems, Leiden, the Nether- titative values for left ventricular (LV) end-diastolic lands). After endocardial delineation, EDV and ESV (EDV) and end-systolic volumes (ESV), and ejection were identified as the frames with maximal and minimal fraction (EF). Regional values of LV wall motion cavity volume. Regional contractility was analyzed (LVWM) and thickening (LVWT) were generated for visually by two experienced readers at rest and during each coronary artery territory, i.e., left anterior descend- dobutamine infusion.
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